TECHNICAL COMMUNICATIONS IN THE MEDICAL SURGICAL NURSING UNIT.

Slides:



Advertisements
Similar presentations
Patient Rights and Confidentiality. Inform Patient of their Rights  Upon admissions  Written information available in English and Spanish  Non-English.
Advertisements

Sharp Healthcare Interpreting Program. agenda 2 » Overview » SIGNS » Education » Web Site.
National Health Information Privacy and Security Week Understanding the HIPAA Privacy and Security Rule.
The Health Insurance Portability and Accountability Act of 1996– charged the Department of Health and Human Services (DHHS) with creating health information.
NAU HIPAA Awareness Training
HIPAA How can you maintain patient privacy and confidentiality? General Medicine LCCA.
HIPAA HIPAA Health Insurance Portability and Accountability Act of 1996.
Jeff Reece, RN, MSN, MBA Chief Executive Office Chesterfield General Hospital.
Information for Decision Makers Acknowledgement: Adapted from Liverpool CCG, with kind permission.
Integrating the Healthcare Enterprise™ (IHE) Patient Care Coordination Functional Status Assessments.
Learning objectives:- 1. Introduction. 2. Define health record. 3. Explain types of health record. 4. Mention purposes of health record. 5. List general.
Improving Patient Outcomes Through Effective Teaching The Teach Back Method.
Medical Reports Dr. Nasser Al - Jarallah.
Medication History: Keeping our patients safe. How do we get all of the correct details?
How the MEDISCRIBE © System Works © clark 2010 ASSISTED LIVING ASSISTED LIVING MEDISCRIBEMEDISCRIBE© Copyright © Clark 2010 – Patent Pending ALL RIGHTS.
1.02 ANALYZE METHODS TO CORRECTLY MAINTAIN VETERINARY MEDICAL RECORDS VETERINARY MEDICAL RECORDS.
Patients Bill of Rights. What is a Patient’s Bill of Rights? A list of patients rights. It offers guidance and protection to patients by stating the responsibilities.
Medical Surgical Nursing Unit
2 nd Training Seminar on Planning and Preparing for EHES at the National Level Key points regarding informed consent Susanna Conti Istituto Superiore di.
Consent Training Module Version 4: August 7th, 2013.
South Tees Hospitals Hospital Discharge Bev Walker Assistant Director of Nursing and Patient Safety Patients are central to everything we do.
Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 31 Admitting, Transferring, and Discharging Residents.
Next ETCH Confidentiality and HIPAA Annual Review What you need to know. The Privacy Rule 1.
Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Health Information Technology and Management Richard.
Randomized controlled trial to evaluate a focused communication intervention to reduce length of stay for critically ill children in a pediatric intensive.
Copyright © 2008 Delmar Learning. All rights reserved. Unit 8 Observation, Reporting, and Documentation.
Established in 1996 to enforce standards for electronic health information & enhance the security and privacy of health information.
H I P A A T R A I N I N G Self Directed Module 7 Research Disclosures For Data Custodians START Click to begin…
Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.
Communicating With the Health Team
Observation, Documentation, and Reporting to the RN
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 9 Continuity of Care.
NRCPAD Facilitating Advance Directives for Mental Health Care Christine M. Wilder, M.D. Department of Psychiatry Duke University School of Medicine.
Documentation!. Documentation and Reports Communicate information about clients healthcare needs Ensures that all goals and interventions are directed.
Chief Residents’/Fellows’ Meeting on Patient Safety JCI Preparation of Trainees 9 June 2015.
HIPAA BASIC TRAINING MODULE 1C – Overview (For staff who do not generally create Protected Health Information) Anderson Health Information Systems, Inc.
NORTH AMERICAN HEALTHCARE PHYSICIAN ORDERS FOR LIFE SUSTAINING TREATMENT (POLST)
Child/Youth Care Management 2015 training. WELCOME!
PATIENTS’ RIGHTS Dr. Suheab A. Maghrabi MBBS, MSc.
Rhonda Anderson, RHIA, President  …is a PROCESS, not a PROJECT 2.
HIPAA LAWS.  Under the privacy rule, the patient must give consent to use his or her Protected Health Information.  Examples in which consent must be.
Confidentiality Region 7 Education Service Center Head Start Copyright 2013 by Region 7 Education Service Center. This document may be reproduced for educational.
Perioperative Nursing Care
Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. UNDERSTANDING HOSPITAL BILLING AND CODING CHAPTER 3 Hospital Organizational Structure and.
RML Specialty Hospital FALL PREVENTION PROGRAM NATIONAL NALTH WINNER 2006 for BEST PRACTICE.
Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 34 Admissions, Transfers, and Discharges.
Unit: Ethical and Legal.   Client Autonomy  The right of patients to make decisions about their medical care without their health care provider trying.
The Medical Record, Documentation, and Filing
Established standards of care given with respect and consideration, regardless of race, age, or payment source. Information about your illness, possible.
Documentation and Reporting
Chapter 29 Admissions, Transfers, and Discharges All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
UNITS 4:3-4:4 Patients’ Rights and Legal Directives for Health Care.
PATIENT & FAMILY RIGHTS AT DOHMS. Fully understand and practice all your rights. You will receive a written copy of these rights from the Reception, Registration.
© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.
Chapter 1 Introduction to Electronic Health Records Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Medical Documentation CHAPTER 17. Purposes of Documentation  Communication  Most patients receive care from more than one source  Allows all health.
Disclaimer This presentation is intended only for use by Tulane University faculty, staff, and students. No copy or use of this presentation should occur.
 Proposed Rule by the Centers for Medicare & Medicaid Services on 11/03/2015Centers for Medicare & Medicaid Services11/03/2015  Revises the discharge.
HANDOFF REPORTING Using SBAR for exchange of information.
Incidental Medical Services (IMS) Department of
Admissions, Transfers, and Discharges
Documentation and Reporting
Privacy & Confidentiality
Patient Medical Records
Disability Services Agencies Briefing On HIPAA
Move this to online module slides 11-56
Emergency Department EMTALA Education
Consent Training Module
HIPAA SECURITY RULE Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Presentation transcript:

TECHNICAL COMMUNICATIONS IN THE MEDICAL SURGICAL NURSING UNIT

 First contact will be notice of an admission onto the unit, by Voice Care report.  Prepare standard floor chart (ie.. demographics, history & physical, medication lists, consent for treatment forms, release of information forms, and advance directives).  Patient room assigned by House Supervisor (person responsible for monitoring staff, patient, and available bed numbers).  Patient arrives on unit from transferring department (ie.. surgery, ER, ICU, L&D, or a cardiovascular unit ). MEDICAL SURGICAL NURSING UNIT

TO RESUSCITATE OR NOT TO? Always identify those patients who are DNR’s, or specific categories of resuscitation. The last thing you want to do, is go against a patient’s wishes.

 Patient information on electronic chart  Use to update established patient information, look at reports (ie.. Surgery, x-ray, labs, medication lists)  Communication between medical staff involved in direct patient care. Serves as a legal document for hospital and patient. COMPASS MEDICAL SOFTWARE

 This form will be the format on your screen in Compass  It is used at every patient admission, regardless, if they are a frequent flyer. PATIENT HISTORY & PHYSICAL

 This form is used to identify the pain or injury location, the patient is experiencing.  Please go over the pain scale with the patient, sometimes there pain maybe more/less intense than they can explain. ASSESSMENT FORM

 The Medical Consent form is used anytime a patient is admitted. This authorizes our healthcare staff to treat the patient.  There are various medical consent forms used (ie..Anethesia, surgery, blood products). Ensure the patient understands all risks pertaining to the appropriate procedure. CONSENT FOR TREATMENT

RELEASE OF INFORMATION  Release of information form (ROI) is used for obtaining, or sending private health information (PHI) specified by patient.  PHI should never be released without patient signed consent, or sent through a device which does not follow confidentiality rules.

ADVANCE MEDICAL DIRECTIVE  A written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out.  A living will allows you to document your wishes concerning medical treatments at the end of life.

 Utilize specified medical forms (use interpreter services if needed).  Every form serves a purpose in the patient electronic chart.  Remember : if you don’t chart it, then it wasn’t done!  Let’s focus on the patient, and not exhaust them with countless forms.  Use of the electronic chart enables this feature.  Our Goal: is to break the communication barrier, and keep it simple. CONCLUSION

 Seton Family of Hospitals © Seton Healthcare Family  Free Printable Medical Form Copyright © by Savetz Publishing, Inc. Publishingwww.freeprintablemedicalforms.com/  Clip art © 2013 Clipart.com, a division of Getty Images Images CITATIONS

Feedback: Privacy Policy Feedback
Do Not Sell My Personal Information
About project: SlidePlayer Terms of Service

© 2025 SlidePlayer.com. Inc. All rights reserved.